Physical Therapy for

Adolescents thru Adulthood

with Down syndrome PATRICIA SHIMANEK, PT, DPT AND ANDREA GADSON, PT, MPT

Andrea Gadson, PT, MPT is a Physical

Therapist at Advocate-Aurora

Lutheran General Hospital. She has

been a Physical Therapist for 22 years

with 20 of those years focused

specifically on out patient sports

medicine. She has found a niche

treating foot and ankle injuries and

had additional training in orthotics

and foot wear. She graduated from

Washington University in St. Louis

ANDREA

GADSON, PT, MPT

Patricia Shimanek PT, DPT is a

Physical therapy at Advocate-

Aurora Lutheran General

Hospital, and has been a PT for almost 30yrs. Graduated from

Northwestern University in 1988

with a bachelors in PT and from

Rosalind Franklin University in 2011

with her doctorate in Physical

Therapy. She has been treating

Ortho/Sports Medicine clients for

28 years. She is also a parent with

a 22 y. o. male with Down syndrome.

PATRICIA

SHIMANEK PT, DPT

Objectives

1. Understanding Medical issues in a person with Down

syndrome

2. Understanding physical characteristics of a person with

Down syndrome

3. Understanding gait tendencies, shoe wear and orthotics

4. Understanding why exercise/Physical Therapy is important

5. Functional Physical Therapy Goals

Medical Issues

There are multiple medial issues related to Down syndrome:

1. Heart Problems(50%) 2.Gastrointestinal Issues 12%

3. Umbilical hernias 4. Epilepsy

5. Orthopedic Issues 6. Ears, nose, and throat issues

7. Blood problems 8. Thyroid issues 4-18%

9. Eye Issues 10. Skin/dermatology concerns

11. Dental issues 12. Alzheimer’s

13. Obesity 14. Obstructive sleep apnea 50-79%

15. Pelvic floor dysfunction

Heart Issues

Approximately 40-60% of infants have some type of heart issue

These are mostly correctable

As the children age, periodic rechecks with the cardiologists are still

important

Coronary Artery disease is not common in Down syndrome, but risk

can increased with obesity and sedentary lifestyle as age.

Valvular heart disease: mitral and aortic valve regurgitation, and aortic and pulmonic stenosis is higher

Gastrointestinal Issues

Celiac disease: sensitivity to gluten

Lactose Intolerance

Irritable Bowel Disease (IBS)

Gastrointestinal Reflux Disease (GERD)

Constipation

Hernias

• Defect in the abdominal wall:

• 1. Inguinal: in the groin

• 2. Umbilical: at the belly button

• 3. Epigastric: above the belly button

• 4. Site of previous abdominal surgery

Orthopedic Issues

2 types that involve bones, joints, ligaments, or tendons

1. Problems caused by ligament laxity

a. Atlantoaxial instability (AAI) 15% b. Hallux Valgus (bunions)

c. Over pronation of the ankles d. Subluxation of the patella 5-9%

e. scoliosis 50% f. hip instability 5-8%/Subluxations 12%

2. Problems associated with aging

a. Osteoarthritis at a young age b. Spinal stenosis

c. Osteoporosis

Alzheimer’s disease

Is a progressive degenerative neurological condition

that affects the brain

In the general population, the incidence of Alzheimer’s

is 10% of people in their 60’s, 20% in the 70’s, 40% in the

80’s and 50% above 85

It appears that the incidence of AD is the same in the

Down syndrome world, but starts 20 years earlier

Physical Characteristics

Hypotonia

Decreased strength

Increased joint flexibility/hypermobility

Short arms and legs

Stature

Facial features: nose, eyes, mouth, ears, teeth and head shape

Hands and feet

Hypotonia

Decreased or low tone

Muscle tone is different then strength

1. Tone is the resting tension of the muscle.

2. Muscles feel more “floppy” or relaxed

This is determined by the lack or decreased resistance, stiffness or tension of the muscle when passively moved

Usually affects all the muscles, but can be different in various locations in the body: L side may be less than R, Uppers more than Lower extremities.

Predominant in infants, and slowly reduces with age

Decreased strength

Muscle strength is defined as the force needed to overcome

resistance

With time, repetition and practice, strength can be improved

As gross motor movements are learned, strength needs to be developed in the desired movements

* With the baby’s own movements, compensatory patterns may

develop and then stay thru adulthood

Increased Joint Flexibility/Ligamentous Laxity

Ligaments’ role is to hold bones together

They are looser in people with Down syndrome

This allows excess movement in the joints

Joints most laxity seen in: hips, shoulders and neck

What to do:

1. teach gross motor skill

2. prevent further stretching

3. strengthen muscles around the joints

4. lift carefully

Examples

Short Arms and Legs

Children with Down syndrome have short arms and legs in relation

to their torsos

This will make it more difficult to learn to:

1. Sit since cannot reach hands to floor

2. Climb onto sofa, stairs and curbs

3. Pedal or steer a bike; may need to wait till older or look for more

proportioned equipment

Stature

Babies with Down syndrome are usually born with

typical heights/weights

They do not grow as fast as children without Down

syndrome

*Average height for males with DS is 5 feet, 2 inches

*Average height for females with DS is 4feet, 9 inches

(these are from most recent studies for the United States)

Examples of short arms/legs and stature

Facial Features

Nose: may be broader and flatter and smaller nasal passages

*easier to get congested and last longer

Eyes: May slant upward and have small extra fold of skin in the corners

Mouth: may be small and roof shallow

* tongue may protrude, especially with low tone

Teeth: May come in late, different order or not at all

Ears: Small, tops fold over, small passages

* easily blocked by wax, cause hearing loss, increased infections

Head shape: smaller than normal, flatter back of head and shorter neck

Hands and Feet

Hands:

1. smaller

2. shorter fingers

Feet:

1. Gap between 1st and 2nd toe

2. Flat feet

Example

Examples

Gait, Posture, Shoe wear

and Orthotics

Gait Tendencies

Heavy footed pattern

Flat arches, primary weight bearing on inside border of

foot

Walk with feet turned out

Complaints of foot pain and significant callousing

Tight heel cords/resulting in rigidity at the ankles

Benefit of good shoe wear

Improves posture- not just at the feet but up the chain

Foot alignment-improved mechanics at the feet/endurance

Improves balance-uneven ground/reducing risk of

ankle/knee instability

Examples of good vs poor shoe wear

Good

Athletic shoes- New Balance,

Asics, Brooks

Dress shoes- Merrils, Clarks,

Sandal-built in arch support/heel

strap

Poor

Athletic shoes- with no support-

Nike free, Sketchers

Canvas shoe with no support-

Converse, Toms

Flip flops, high heels/wedge

Ugg

Benefit and limitations of

inserts/orthotics

Extension of the shoe

All of the benefits for that you get shoe but more of it

Does not fit in every shoe

Helps if you are able to take out the insole

Does not work with a sandal but some can have them built into them-Birkenstock/Langer

Differences between devices

Inserts/over the

counter Arch support-no posting

Vary in stiffness from gel to

harder plastic

Found in many stores-

Walgreens, Dicks, Running

shoe stores

Last a few months to a few

years

Least expensive

Semicustom

orthotics Prefab orthotics- Vasyli

Sizing-small, medium, large

Density-low, med, high

Post built in-heat out or add

to it

Take home same day

Less expensive than a custom

Last 1-3 years

Custom Orthotics Casted- to exact size and

shape of foot

Customize the material

Can tailor to shoe type and

activity-dress shoe, soccer

cleat

Can add lift, first ray cut out,

flanges, deepen heel seat

Cast is sent out so a delay to

receiving

Most expensive

Last 3-5 years

Why is Physical Therapy important for

my person with Down syndrome?

“Physical therapy is a critical service, not because it

will accelerate a child’s rate of development, but

because it will improve a child’s long-term

functional outcome” Patricia Winders, PT

“The goal is to minimize the development of

Abnormal compensatory movement patterns that

children with Down syndrome are prone to

develop” Patricia Winders

Four critical areas to improve

1. Normalized gait pattern:

a. walk with feet and knees pointing straight ahead

b. a narrow base of support

c. a long stride

d. to be able to toe off

2. Postural alignment

Optimal alignment of hips, knees and ankles to support this walking pattern

Four critical areas continued

3. Postural strength

a. Strong, upright trunk

b. Balanced strength between back and abdominal

muscles

4. Extremity strength

a. Strong arms/shoulders

b. Shoulders should be in middle of side view not forward

Postural alignment

Why is it important to correct these?

When these four areas are achieved:

1. The child can develop a body with a solid foundation

2. This will support exercise and fitness throughout their life span

*Typical children develop naturally, but a child with Down syndrome is prone to develop compensations

*Therefore, developing physical problems as they grow

So…Why need Physical Therapy and

exercise

Decrease CAD ( coronary artery disease)

Exercise has shown decrease risk in development of CAD

Decrease obesity

Less weight to carry around

Ease of movements

Less strain/pressure on joints

Improved posture

Decrease OA(osteoarthritis)

Decrease sedentary life style

Decrease osteoporosis risk

Become a more functioning part of society

Why Physical Therapy and exercise

continued

Improve overall mobility/function

Less wear and tear on joints

Participation in general physical education

More active in home, school and community activities

Normalize movement patterns

Improved gait patterns

Improve postural alignment

Physical therapy and exercise

continued

Improve muscle strength

allow improved ability to walk, sit, stand

dress independently

balance activities

overall wellness

improved postural alignment

Improved control of ligament laxity

Physical therapy and exercise

Decrease constipation

increased core strength

increased exercise can promote improved digestion/motility

Decrease/slow down Alzheimer’s symptoms

Physical activities may improve cognition

Decrease Osteoarthritis/osteoporosis

Improved activity level

Increase strength around joints/dec. ligament laxity movements

Maintain ideal body weight

Functional Physical Therapy Goals

1. Improve muscle strength to allow standing for 3-4 hours

in the home, community/work

2. Improve balance to allow independent gait on level/un

level surfaces

3. Increase balance to allow independent dressing at

home, school and in the community

4. Increase balance to allow stair climbing

5. Improve foot positioning to improve gait mechanics

Functional goals continued

6.Improve foot positioning to allow longer standing

/walking in the community/work/school

7. Improve lower extremity (LE) posturing to return to more

normalized loading thru joints

8. Increase LE/core strength to help support posture to

normalize load thru joints

9. Restore normal movement patterns to decrease wear

and tear on joints

Resources

1.Special Olympics: have exercise videos on line

2. Local SRA have exercises classes, sports activities,

nutritional classes, etc.

3. Adult Down syndrome clinic: has videos and classes

4. Physical therapy locations

5. Local fitness centers and workout clubs: some specific

to people with special needs

Any

questions?

Thank you

for letting us

present to

you today!!!

References

1. Winders, P.C. (2014).Gross motor skils for children with down syndrome: a guide for parents and professionals. Bethesda, Maryland, Woodbine House.

2. Skallerup, S.J. (2008). Babies with down syndrome: a new parents’ guide. Bethesda, Maryland, Woodbine House.

3. Chicoine, B and McGuire, D. (2006). Mental wellness in adults with down syndrome: a guide to emotional and behavioral strengths and challenges. Bethesda, Maryland, Woodbine House.

4. Cohen, W. I., Nadel, L., Madnick, M.E. (2002). Down syndrome: Visions for the 21st century. New York, New York, Wiley-Liss, Inc.

5. Chicoine, B and McGuire, D. (2010).The guide to good health for teens and adults with down syndrome. Bethesda, Maryland, Woodbine House

References

6. Mann, S. (2017, December 5). Get moving, be awesome! Physical therapy for

adolescents and adults with Down syndrome. Global Down syndrome foundation’s

webinar series

7. Bull MJ, Committee on G. Health supervision for children with Down syndrome.

Pediatrics. 2011;128(2): 393-406

8. Mahy J, Shields N, Taylor NF, Dodd KJ. Identifying facilitators and barriers to physical

activity for adults with Down syndrome. Journal of intellectual disability research: JIDR.

2010;54(9):795-805

9. Ptomey LT et al. Changed in cognitive function after a 12-week exercise intervention in

adults with Down syndrome. Disability Health J. 2018

References

10. Ngandu, T et al. A 2 year multidomain intervention of diet, exercise, cognitive

training, and vascular risk monitoring versus control to prevent decline in at-risk

elderly people (FINGER): a randomized controlled study. The Lancet. 2015;vol 385

11. Moris JK et al. Aerobic exercise for Alzheimer’s disease: A randomized

controlled pilot trial. PLoS ONE 12(2): e0170547.

https://doi.org/10.1371/journal.pone.0170547

12. Roig, M, Neilsen J B. The effects of cardiovascular exercise on human memory:

A review with meta-analysis. http://doi.org/10.1016/j.neubiorev.2013.06.012